Nursing Elites

1. A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential nursing problem has the highest priority when planning nursing care for this client?

• A. Ineffective airway clearance
• B. Altered nutrition less than body requirements
• C. Fluid volume excess
• D. Activity intolerance

Correct answer: A

Rationale: In this scenario, the highest priority nursing problem for the postoperative client following a ureterolithotomy via a flank incision is ineffective airway clearance. After surgery, there is a risk of airway obstruction due to factors like anesthesia, positioning during surgery, or the presence of secretions. Maintaining a clear airway is crucial to prevent respiratory complications, such as atelectasis or pneumonia. Altered nutrition, fluid volume excess, and activity intolerance are important considerations but are secondary to the immediate threat of compromised airway clearance in the postoperative period.

2. A client has had several episodes of clear, watery diarrhea that started yesterday. What action should the nurse implement?

• A. Administer a prescribed PRN antiemetic
• B. Assess the client for the presence of hemorrhoids
• C. Check the client’s hemoglobin level
• D. Review the client’s current list of medications

Correct answer: D

Rationale: The correct action for the nurse to implement in a client experiencing clear, watery diarrhea is to review the client's current list of medications. Certain medications can cause diarrhea as a side effect, so identifying any potential culprits is essential. Administering an antiemetic (Choice A) is not appropriate for diarrhea, as antiemetics are used to control nausea and vomiting, not diarrhea. Assessing for hemorrhoids (Choice B) is not the priority when the client is experiencing watery diarrhea; addressing the root cause is crucial. Checking the client’s hemoglobin level (Choice C) is not the immediate action needed for this situation as it does not directly address the cause of diarrhea.

3. The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping, and aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication?

• A. Ask the client about soft food preferences
• B. Auscultate the client’s breath sounds
• C. Obtain and record the client’s vital signs
• D. Determine which side of the body is weak

Correct answer: B

Rationale: The correct answer is to auscultate the client’s breath sounds. Assessing breath sounds is crucial in this scenario as it helps ensure that the client can safely swallow the oral antibiotic without aspirating. Unilateral weakness, ptosis, mouth drooping, and aspiration pneumonia indicate potential swallowing difficulties, making it essential to assess breath sounds for any signs of respiratory issues. Asking about food preferences (choice A) may be relevant later but is not the priority before administering the medication. While obtaining vital signs (choice C) is important, assessing breath sounds takes precedence in this case. Determining which side of the body is weak (choice D) is not the priority assessment before administering the oral antibiotic.

4. The nurse assesses a 5-year-old child who has been experiencing frequent headaches and vomiting. The nurse notices that the child is lethargic and has a positive Brudzinski sign. Which action should the nurse implement first?

• A. Perform a complete neurological examination
• B. Measure the child’s head circumference
• C. Check the child’s blood glucose level
• D. Notify the healthcare provider immediately

Correct answer: D

Rationale: The correct action for the nurse to implement first is to notify the healthcare provider immediately. The presence of lethargy and a positive Brudzinski sign in a child experiencing frequent headaches and vomiting may indicate a serious condition like meningitis. Prompt notification of the healthcare provider is crucial for timely evaluation and initiation of appropriate treatment. Choice A is incorrect because while a neurological examination may be necessary, it is not the priority when a potentially serious condition like meningitis is suspected. Choice B is incorrect as measuring the child's head circumference is not the most immediate action to take in this situation. Choice C is also incorrect as checking the child's blood glucose level, although important in some cases, is not the priority when a child presents with symptoms suggestive of meningitis.

5. After undergoing an uncomplicated gastric bypass surgery, a client is experiencing difficulty managing their diet. What dietary instruction is most important for the nurse to explain to the client?

• A. Chew food slowly and thoroughly before attempting to swallow
• B. Plan volume-controlled evenly spaced meals throughout the day
• C. Sip fluid slowly with each meal and between meals
• D. Eliminate or reduce intake of fatty and gas-forming foods

Correct answer: A

Rationale: The correct answer is A. Thoroughly chewing food is crucial for clients who have undergone gastric bypass surgery to aid in digestion and prevent complications. Proper chewing helps break down food into smaller particles, making it easier for the digestive system to process. This instruction is essential to prevent issues such as food blockages or inadequate nutrient absorption. Choices B and C are also important for post-gastric bypass clients to maintain proper nutrition and hydration, but they are not as critical as ensuring thorough chewing. Choice D addresses dietary concerns but is not as immediately crucial as ensuring the client chews food properly to support digestion and prevent complications.

Similar Questions